Family and Children's Medicaid MA-3255 NC HEALTH CHOICE

VI. ONGOING CASE MAINTENANCE

Always inform the applicant to report changes in situation. How the dss reacts to the reported change is outlined below in the chart with instructions for changes in situation. Use the chart to help in determining appropriate action when a change in situation occurs which may affect a NC Health Choice household.

CHANGES IN HOUSEHOLD SITUATION

TYPE OF CHANGE	ACTION REQUIRED?	COMMENTS
Address of entire AU changes	Yes	Change address in EIS
NCHC child leaves the home; other children remain The child moves into household not authorized for NCHC The child moves into another NCHC household	No No No	No change in case until reenrollment. Child remains in the AU Evaluate eligibility at reenrollment. At end of child’s enrollment period, add to remainder of NCHC period in new household if the child is ineligible for Medicaid. Update needs unit and maintenance amount. Do not change classification or income.
Child not authorized for NCHC or Medicaid enters NCHC household	Yes	Evaluate for Medicaid. If ineligible for Medicaid and child does not have comprehensive insurance, add to NCHC case. Update needs unit and maintenance amount. Do not change classification or income.
Child receiving Medicaid has change in situation and Medicaid is terminated.	Yes	If no NCHC case for household, evaluate child for NC Health Choice. If eligible, approve administrative application for NCHC. If others in household already receiving NCHC and MA child does not have comprehensive insurance, complete add-on application to approve NCHC for this child. Update needs unit and maintenance amount. Do not change classification or income.
One child is deleted (no longer eligible) from NCHC case which has more than one child.	Yes	In EIS, adjust needs unit and maintenance amount. Do not change classification or income.
Budget unit member not authorized for NCHC leaves the home permanently.	No	Evaluate eligibility at reenrollment.
Family moves to another county	Yes	Complete county transfer in EIS. 2nd county does not have to review until reenrollment.
Income increases above 150% of FPL or below 200% of FPL	No	No change until reenrollment.
Income decreases to below MIC income limit	No	No change until reenrollment, unless recipient requests termination to allow them to apply for Medicaid.
Child moves out of state	Yes	Terminate if only case member. Delete if other children are in the NCHC case. Do not change classification or income.

TYPE OF CHANGE	ACTION REQUIRED?	COMMENTS
Classification code erroneously used	Yes	Change during enrollment period unless 2 or fewer months prior to reenrollment.
Child acquires comprehensive health insurance (including Medicare)	Yes	Follow instructions for child moves out of state.
Child dies	Yes	Follow instructions for child moves out of state.
Child is incarcerated	Yes	Follow instructions for child moves out of state.
Child becomes eligible for Work First	Yes	Follow instructions for child moves out of state.
Child is removed by DSS and is eligible for HSF/IAS.	Yes	Delete or terminate. Approve HSF/IAS. If child is later returned to parental custody during same NCHC enrollment period complete an administrative reapplication against the terminated NCHC case id (or add to existing a.u.) using the original date of application and the original certification period to authorize NCHC for the remainder of the original enrollment period. The effective date of coverage is the month following month of HSF/IAS termination.
Child becomes SSI eligible	Yes	System will authorize child for Medicaid. If other children remain in the NCHC case, change the # in the needs unit and maintenance level. Do not change classification or income. If child’s SSI stops during original NCHC enrollment period, complete an administrative reapplication against the terminated NCHC case id (or add to existing a.u.) using the original date of application and the original certification period to authorize NCHC for the remainder of the original enrollment period. The effective date of coverage is the month following month of SSI MA termination.
Head of Household requests termination	Yes	Terminate case
Child marries	No	Leave in the NCHC case.
Child turns age 19	Yes	Delete or terminate child
Child enters Long Term Care	Yes	Evaluate for Medicaid. If eligible, delete or terminate NCHC and approve Medicaid. If ineligible for Medicaid, continue NCHC coverage.
NCHC recipient becomes pregnant	Yes	Evaluate for Medicaid. If eligible, delete or terminate NCHC and approve ongoing Medicaid. Contact Claims Analysis Section at DMA if eligible for Medicaid coverage of “retroactive” pregnancy related services received during months of NCHC eligibility. Do not attempt to enter eligibility in EIS for these months. If ineligible for Medicaid, continue NCHC coverage.

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(VI)

A. Changes in Income

Do not apply reported changes in income until the end of the 12 month enrollment period. Increases or decreases in household income do not affect eligibility or cost sharing for NC Health Choice. However, the recipient is notified as part of the application process to report changes in situation as it may not be known prior to disposition whether approval is for NC Health Choice or for one of the Medicaid categories. Document reports of a change in income in the record.

1. Most children will remain eligible under NCHC for the full 12 month certification (continuous eligibility) even if a change in income would result in Medicaid eligibility.

2. At re-enrollment, compare verified income with reports of changes. Question discrepancies unless the reason is clear, such as the number of weeks worked is higher or lower.

B. Change of Address

1. Change the address in EIS only if the entire assistance unit's address changes.

2. When a child in a multiple a.u. leaves the home to live elsewhere (e.g., goes to live with another parent) he remains eligible in the established a.u. for the entire 12 month enrollment period as long as he lives in NC.

a. Document the move in the case record. (Question the parent/caretaker about his location if he is included on the reenrollment form at the end of the 12 months.)

b. Do not make changes to the case in EIS. Refer to the chart, Changes In Household Situation, in VI, above.

c. Remind the caretaker to give the child's ID card to him or to his new caretaker.

d. At re-enrollment, send a DMA-5063 (DMA-5063, Spanish), Medicaid/NC Health Choice Application, or DMA-5063R/DMA-5063RS, Health Check/NC Health Choice Re-Enrollment Form to the child at his new address.

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(VI.2.)

C. Changes Which Result in Termination

Note: Do not refund enrollment fees when recipients are terminated or deleted from the NC Health Choice assistance unit.

Terminate (or delete) a recipient from NC Health Choice coverage who:

1. Acquires comprehensive health insurance or Medicare. See MA-3510, Third Party Resources, for procedures for entering insurance.

2. Moves out of the state. If recipient moves back to the state within original 12 month enrollment period and applies for NCHC again, assign a new enrollment period. Do not use the old case ID. Worker should complete a new application with a new case ID.

3. Is deceased.

4. Requests termination of assistance.

5. Turns age 19. Evaluate for other Medicaid categories, including the Family Planning Waiver.

6. Is incarcerated.

7. Becomes eligible for Work First.

8. Is removed from the home by the department of social services for placement purposes and is eligible for HSF or IAS.

a. When a child is placed in foster care, delete the child (or terminate NC Health Choice if only one child) and approve as HSF or IAS.

b. If the child is returned to the home of the parents within the same 12-month enrollment period terminate HSF or IAS. Complete an administrative reapplication against the terminated NCHC case id or, add to existing a.u. to authorize NCHC for the remainder of the enrollment period. The original date of application and original certification from date must be entered into EIS in order for the claims processing contractor to calculate the correct 12-month enrollment period. Authorize the month after Medicaid terminates. See EIS-4300.

c. Do not collect an enrollment fee.

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(VI. C.)

9. Is approved for SSI Medicaid.

a. EIS automatically terminates/deletes the child and authorizes for MAD.

b. If the child is subsequently terminated from SSI during the same 12-month enrollment period, complete an administrative reapplication against the terminated NCHC case id (or add to existing a.u.) to authorize NCHC for the remainder of the enrollment period. The original date of application and original certification from date must be entered into EIS in order for the claims processing contractor to calculate the correct 12-month enrollment period. Authorize the month after Medicaid terminates. See EIS-4300.

c. Do not collect an enrollment fee.

10. Is eligible for CAP services or Medicaid for payment of long term care services. (Contact the Claims Analysis Section at DMA (919) 855-4045 if Medicaid eligibility needs posting for months in which the recipient was authorized for NC Health Choice).

11. Is pregnant and eligible for coverage under MPW, MIC, or MAF.

a. Complete an eligibility determination to assure that the recipient is eligible for Medicaid. Verify pregnancy and document eligibility in the case record.

b. Treat as an administrative application. Enter an unsigned 8124 in EIS. The date of application is the date the recipient requests coverage.

c. Approve ongoing eligibility effective the month after NC Health Choice terminates. Do not attempt to update eligibility in EIS for months already covered by NC Health Choice.

d. Contact the Claims Analysis Unit in DMA at (919) 855-4045 if "retroactive" coverage of pregnancy related services is needed. A Claims Analyst will take the information necessary to provide coverage.

e. Refer further inquiries about pregnancy related services to Claims Analysis.

f. If a pregnant woman is deleted from NCHC, goes to MPW, and then is eligible again for NCHC, use the original 12 month enrollment period if still in that 12 months. Complete an administrative reapplication against the terminated NCHC case id or, add to existing a.u. to authorize NCHC for the remainder of the enrollment period. The original date of application and original certification from date must be entered into EIS in order for the claims processing contractor to calculate the correct 12-month enrollment period. Authorize the month after Medicaid terminates. See EIS-4300.

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(VI.C.)

12. Is pregnant and presumptively eligible.

a. Hold the presumptive eligibility determination until the pregnant woman requests Medicaid or until the last workday of the month following the month of the presumptive eligibility determination.

(1) If the pregnant woman requests and is eligible for Medicaid proceed with items b. and c. below. This is an administrative application. A signed application is not required.

(2) If the woman does not request Medicaid by the last workday of the month following the month presumptive eligibility is determined or is determined ineligible for Medicaid, she is eligible only for presumptive eligibility coverage. Call the Medicaid Eligibility Unit at DMA, (919) 855-4000, for instructions on entering presumptive eligibility coverage.

b. Once eligibility is determined for MPW, send an adequate notice to terminate North Carolina Health Choice.

c. Follow same procedures as in 11.a. through e above.

Send an automated timely or adequate notice as appropriate. Always document the circumstances and reason for termination in the case record.

D. Classification Changes

1. Cases Authorized In Error for NCHC that should be MIC-N, MIC-1 or MAF

a. Overlay existing “J”, “K”, “S”, or “A” classification only for CAP, long-term care recipients, or coverage of pregnancy related services as specified in C. 10, 11, and 12, above.

b. Begin coverage on the first day of the month following the month in which NCHC coverage terminates. Please Note: If the error is found within two months of re-enrollment, make the change at re-enrollment.

2. Cases Authorized In Error For Incorrect NCHC Class

If a NCHC case is approved into an incorrect classification code in error, the code can be changed during the 12 month enrollment period, effective with the ongoing month. If the change is within the two months prior to re-enrollment, make the change at re-enrollment.

Counties will be subject to being charged the premiums paid for any months in which the recipient(s) is authorized in error.

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(VI.D.2.)

a. If “J” code is erroneously used instead of “K” code, the classification code may be changed during the enrollment period or at re-enrollment. The change will always be effective the ongoing (EIS Processing) month. If the error is found within two months of re-enrollment, make the change at re-enrollment.

(1) Send a manual timely notice.

(2) The county will be responsible for any possible overpayments.

(3) The county cannot request that the family pay an enrollment fee during the current enrollment period.

b. If “K’ code is erroneously used instead of “J” code, the classification code may be changed during the enrollment period or at re-enrollment. The change will always be effective the ongoing (EIS Processing) month. If the error is found within the two months prior to re-enrollment, make the change at re-enrollment.

(1) Send a manual adequate notice.

(2) The county will be responsible for refunding the enrollment fee to the client. There is no recourse for the family to be reimbursed for any prescription co-payments they may have been required to pay during the time the case was in error.

c. See II.A.9.c., above Exemption for Federally Recognized Indian Tribes/Alaskan Natives, for changes concerning “S” and “A” codes.

3. Cases Authorized in Error for Medicaid that should be NCHC

The Claims Unit charges 100% to county funds when the county has incorrectly authorized an individual for Medicaid, and EIS shows authorization for NCHC if a provider demands Medicaid payment.

E. Transfer to Another County

If all individuals in the case move to another county:

1. County 1 (the original county of residence)

Transfer the case following procedures and time frames outlined in MA-3340, County Residence.

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(VI.E.)

2. County 2 (the receiving county)

a. Review the case when eligibility is redetermined at the end of the 12-month enrollment period unless the recipient reports a change in situation that affects NC Health Choice eligibility.

b. Do not require the family to pay any additional enrollment fee when transferring to another county.

Note: Do not make changes to the case if only a portion of the assistance unit moves to another residence, including moves to another county. County 1 should send aDMA-5063 (DMA-5063, Spanish), Medicaid/NC Health Choice Application, for the children at the new address.

F. Individuals Placed in Nursing Facility/ICF-MR or PRTF

An individual who will receive medical treatment in a long term care facility or Psychiatric Residential Treatment Facility must be evaluated for eligibility for Medicaid. If the child is eligible for Medicaid for payment of long term care:

1. Delete the child from the NC Health Choice assistance unit.

2. Enter an administrative 8124 screen in the appropriate Medicaid category.

3. Complete the 8125 screen to authorize Medicaid. This application counts in the processing standards.

G. Changes In Household Composition

"Continuous eligibility" requires that children be treated in the following manner when a change in household situation occurs which normally would affect Medicaid eligibility.

Note: Contact an EIS consultant if you have questions concerning the classification.

1. A child authorized for NC Health Choice remains in the same NC Health Choice case for the established 12-month enrollment period unless he becomes ineligible for NC Health Choice as specified in C above.

a. If the child becomes ineligible for NC Health Choice, delete him from the assistance unit.

b. Update the needs unit and income level.

c. Do not update the classification code or the total countable income of the household until redetermining eligibility at the end of the enrollment period.

d. The remaining members of the a.u. continue to receive NC Health Choice for the remainder of the enrollment period. This is true even if countable income now exceeds the maintenance allowance. The system does not edit changes in situation.

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(VI.G.)

2. When a child who is not authorized for NC Health Choice or Medicaid enters a NC Health Choice household during the 12 month enrollment period (child age 6 through 18 comes to live with parent or guardian):

a. The family must make an application for the new child.

b. Evaluate for Medicaid eligibility. If the child is ineligible for Medicaid:

(1) Add the child to the NC Health Choice case for the remainder of the enrollment period if the child is uninsured. Do not count his income.

Note: Add the child to the NC Health Choice case even if the caretaker is not financially responsible for the child.

(2) Update the number in the needs unit and the income level.

(3) Do not update the classification code or total countable income until redetermining eligibility at the end of the enrollment period (even if the child has his own income).

(4) Do not charge an additional enrollment fee.

3. When a child who is authorized for NC Health Choice (household #1) moves into a household which is not authorized for NC Health Choice (household #2):

a. The child remains authorized in the original case (household # 1) until the end of the enrollment period.

b. Do not make any changes in EIS.

c. Remind the casehead (household # 1) to give the child's ID card to the child or head of household # 2.

d. At the end of household # 1's enrollment period, the head of household # 2 must apply for the child.

4. When a child who is authorized for NC Health Choice (household #1) moves into another NC Health Choice household (household #2):

a. The child remains enrolled in the original case until the end of the enrollment period of household #1. Do not make changes in EIS. Remind the head of household # 1 to give the ID card to the child or head of household #2.

b. At the end of household # 1's enrollment period:

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(VI.G.4.b.)

(1) Household #2 can apply to have the child added to their NC Health Choice case for the remainder of the re-enrollment period if the child is ineligible for Medicaid without re-determining eligibility.

(2) Add the child to household # 2's existing enrollment without redetermining eligibility. Update the number in needs unit and income level. Do not make changes to the classification code or income, even if the child has countable income.

c. At the end of household # 2's enrollment period, redetermine eligibility for the children listed on the reenrollment form. Evaluate Medicaid eligibility before considering NC Health Choice.

5. If a parent who is a member of the budget unit but not authorized for NC Health Choice leaves the household on a permanent basis make no changes to the case.

H. Automated Re-enrollment in NC Health Choice

1. The re-enrollment in NC Health Choice is completed each year using an ex parte process. EIS automatically sends a Re-enrollment Information Notice (DMA-5067) to each recipient on the 15th day of the 10th month of the current enrollment period. Refer to re-enrollment procedures in MA-3420, Re-Enrollment.

.

2. Evaluate for eligibility for Medicaid first as family composition and/or income may have changed.

a. If any children are now eligible for full Medicaid benefits, authorize under the appropriate category following instructions in EIS 2010 for processing applications for Medicaid.

b. If the child(ren) continues to be eligible for NC Health Choice, authorize for another 12 month enrollment period following instructions in EIS 4300, Part Five, for re-enrolling a North Carolina Health Choice case.

c. If an enrollment fee is due:

(1) Send the family notice of the annual enrollment fee if countable income exceeds 150% of the federal poverty level (See procedures in IV.D., above).

(2) Allow the family at least 12 calendar days to pay the enrollment fee.

(3) Follow instructions in EIS 4300 to approve or deny the re-enrollment period.

REVISED 10/01/11 CHANGE NOTICE 16-11

(VI.)

I. Optional Extended Coverage (200 - 225% of Federal Poverty Level)

If family income at re-enrollment is greater than 200% but equal to or less than 225% of the federal poverty level, the family has the option to pay the full monthly premium charged by DMA and remain on NC Health Choice for a period not to exceed one year. Complete the following steps when determining eligibility:

1. Verify that income falls in the appropriate range (Refer to the NC Health Choice Family Income Levels Chart in II. A., 3., above.)

2. Send a manual timely notice. Inform the family that coverage under NCHC will stop.

3. At the end of the timely notice period, transfer the case to Optional Extended Coverage in EIS for 12 months.

a. Enter adequate change code 53 (see EIS 4300 for instructions). Do not override the notice.

b. Change the classification to "L."

c. Update the certification period in EIS.

d. Children who are authorized as "L" may be in a separate case from other children in the home who are eligible as “J”, “K”, “S” or “A.” The "L" children must remain in the original NCHC case. Open a new case for the “J”, “K”, “S” or “A” children.

4. The Health Choice Extended Coverage Specialist will send to all newly created “L” classified families a letter that will offer them the full premium payment option to continue coverage.

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(VI.I.)

5. The processing and tracking of premium payments is done by the DMA Health Choice Extended Coverage Specialist.

a. If, after 30 days, the families have not replied to the offering letter, the Specialist will deny the case.

b. An invoice for the premium amount is sent to those families who accept the offering letter. A second notice is sent if the premium payment is not received within 30 days. The Specialist will deny/terminate the case if no payment is received within 15 days of the second notice.

c. Premium payments received are tracked in EIS by the Specialist on the Premium Payment screen.

6. The family is not "locked in" to Optional Extended Coverage during the certification period. If the family contacts the county and wishes to apply for Medicaid or NC Health Choice for Children;

a. Have the family complete form DMA-5063 (DMA-5063, Spanish), Medicaid/NC Health Choice Application, to reapply for benefits.

b. Evaluate for Medicaid or NC Health Choice for Children coverage.

c. Refer to instructions in VI.I.9 below for authorizing MIC “J”, “K”, “S”, “A” or “N” for months in which the case was in Optional Extended Coverage status. The IMC views EIS to verify if the family has paid premiums for any of the months for which coverage is requested and follow instructions to authorize coverage.

Note: Once the family is eligible for Optional Extended Coverage, an increase in income over the 225% of poverty limit does not make the family ineligible during the 12 month enrollment period.

7. Families are not allowed to re-enroll into Optional Extended Coverage. A family may only qualify for Optional Extended Coverage again if they later receive NC Health Choice for Children for another 12-month enrollment period, and, are again ineligible for NC Health Choice for Children at re-enrollment due to increased income.

8. A case which terminated with a “J”, “K”, “S” or “A” classification may be reopened into “L” classification if criteria in MA-3420, Re-enrollment, are met.

a. Complete an administrative reapplication against the terminated case. Enter an unsigned 8124 in EIS. Enter "Y" in the ADMIN field on the DSS-8124 screen.

b. Enter disposition code B5.

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(VI.I.8.)

c. Override the automated notice.

9. Authorizing MIC “J”, “K”, “N”, “S”, “A” for a Case Which Is Currently MIC "L"

Recipients potentially eligible for Optional Extended Coverage - (MIC "L") are entered in EIS with a 12 month certification period. Since DMA tracks premium payments, EIS shows whether those payments have been made..

If child(ren) are authorized as MIC "L", follow these procedures when a family applies for a Medicaid program or NCHC:

As soon as the application is taken/received and the Income Maintenance Caseworker is aware that the child(ren) is potentially eligible for Medicaid or NC Health Choice (“J”, “K”, “S”, or “A”), he or she must view EIS to verify if the family has paid premiums.

a. If no premiums were paid:

(1) Enter as a reapplication against the active case.

(2) Evaluate for retroactive coverage (up to 3 months) if potentially Medicaid eligible.

(3) Evaluate for ongoing coverage (12-month certification).

(4) If eligible, terminate the Optional Extended Coverage in EIS. A termination notice is not required.

(5) Approve any retro months of Medicaid for which the child(ren) are eligible and an ongoing certification period of 12 months.

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(VI.I.9)

b. If premiums have been paid:

(1) Do not approve coverage for months in which a premium has been paid as child is already covered by NCHC.

(2) Enter a new application, using a new case ID.

(3) Evaluate for ongoing coverage (12-month certification).

(4) If eligible, terminate the Optional Extended Coverage in EIS. A termination notice is not required.

(5) Coverage can begin no earlier than the first month that premiums were not paid.

(6) Enter an ongoing certification period of 12 months effective with the month of application or the first month in which premiums were not paid, whichever is later.

J. Medicaid Re-Enrollment and Terminated Medicaid/Work First Cases

When completing a re-enrollment or reviewing ineligible Medicaid/Work First cases for ongoing Medicaid, evaluate eligibility for NC Health Choice if the case is ineligible for Medicaid in any other aid program category. (Refer to MA-3410, Terminations and Deletions, and MA-3420, Re-Enrollment.) Terminated cases include cases ineligible due to income or other eligibility factors as well as Transitional Medicaid cases which terminate due to income, failure to return the Transitional Benefit Report or the expiration of the 12-month eligibility period. See MA-3405, Twelve Months Transitional Medicaid.

During the re-enrollment process:

1. Concurrently reverify income and determine whether the recipient(s) has private health insurance. See IV.B., above when reviewing for health insurance.

2. Health Insurance

a. If the child does not have health insurance continue processing the re-enrollment following instructions VI.J.3.a. below.

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(VI.J.2.)

b. If the child has health insurance, verification of the termination of the health insurance must be received by the deadline to complete the re-enrollment timely.

(1) It must be terminated by the end of the current certification period before approving NCHC. See IV.B.3, above for procedures to follow.

(2) To verify that insurance will be discontinued and the effective date of the insurance termination, accept the client’s or the insurance company’s statement that the insurance will be discontinued and effective date of the discontinuance.

(3) If you later learn that the insurance was not terminated after you transferred the case to NCHC, send a timely notice proposing termination of the NCHC case.

(4) If the verification is not provided by the established deadline, the Medicaid case/individual must be terminated. Do not key a DSS-8124.

3. If verification of the terminated insurance is received, determine if the family is eligible with no enrollment or with an enrollment fee.

a. If the family is eligible for NCHC with no enrollment fee:

(1) Authorize NCHC for a 12- month enrollment period.

(2) The enrollment period begins with the month following termination of Medicaid or Work First.

(3) Enter an administrative DSS-8124 in EIS. Enter “Y” in the Health Choice indicator. The date of application is the date entered in EIS.

b. If the family has income over 150% of poverty, they will have an enrollment fee.

(1) Notify the family of the enrollment fee using the DMA-5059, NC Health Choice – Enrollment Fee Notice. Follow procedures in IV.D above.

(2) Allow 12 calendar days for the fee to be paid. See MA-3215, Processing the Application.

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(VI.J.3.b.)

(3) If the fee is paid, key an administrative DSS-8124 with a Health Choice “Y” indicator and approve NC Health Choice. The date of application is the date entered in EIS. See EIS 2012, Completing An Application Form For New Applications, Reapplications, and Add-An-Individual Applications for M-AF, M-IC, M-PW, and M-RF.

c. If a terminated case is reopened within the first 10 calendar days of the following month the enrollment period begins the month following the termination. See MA-3215, Processing an Application.

(Refer to the chart, Changes In Household Situation, in VI. above, for instructions in making changes when a child is terminated or deleted from a case).

4. If the case is eligible for WFFA, a signed DSS-8124 reapplication must be entered in EIS. The date of application is the date signed. This application will be included in the report card.

5. Enroll all NCHC children (except MIC-L) into Community Care of North Carolina/Carolina Access (CCNC/CA). Refer to II.H. above and MA-3435, Community Care of North Carolina/ Carolina Access for instructions on enrollment procedures.

K. Automated Termination at Age 19

NC Health Choice recipients will be automatically deleted/terminated by EIS on "pull night" of the month in which the recipient turns age 19.

1. EIS will send a timely termination notice on the first day of the month. A special review message appears on the case management report.

2. Review each recipient for ongoing Medicaid and update EIS if eligible.